Brookdale Chatsworth

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility.

At 09:30am, Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent visit to deliver final report. LPAs met with Antonio Cortez, Business Office Manager, and explained the reason for the visit. During the initial visit, conducted on 01/23/25, LPA requested resident and staff roster. At 9:15am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Staff Training, relevant to the investigation. At approximately 9:25am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am - 1:30pm, LPA conducted an interview with the Administrator, Health and Wellness Director, one (1) MedTech, four (4) staff and (4) out of seven (7) residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that R1 had been living at this facility for three (3) years. Based on a Physician’s Report (dated on 06/26/24) R1 was able to leave the facility unassisted. Administrator also informed LPA that no major changes have been observed in R1’s mental condition. Facility entry door is always unlocked. Residents/staff may open the door from the inside, however, no one can get in from the outside before 8:00am or after 7:00pm. Interview with S1 revealed that, at approximately 7:30am, S1 conducted morning routine and visited R1’s room. S1 stated: “I didn’t see R1, so I assumed that R1 already went to the dining area for breakfast.” After discovering that R1 is not present at the dining area, S1 immediately paged all staff members for an assistance to search for R1. Interview with the Wellness Director confirmed the statement provided by S1 and LPA was informed that WD immediately contacted the Northridge Hospital to report and or obtain information. Hospital nursing station informed WD that around 7:30am, R1 was found by the facility and picked up by 911 Paramedics. As of 8:00am, R1 was admitted to the hospital and was receiving medical care for her injuries. LPA requested R1’s medical records on 01/24/25 and received it on 02/25/25. Review of R1’s medical records revealed that upon admission, R1 was heavily bruised all over his/her face, has a hematoma on his/her forehead and bruising around both yes and down the side of her neck. R1 was unable to recall what happened, stated that he/she may have gotten in a fight. Lastly, LPA conducted interviews with seven (7) residents and four (4) out of seven residents informed LPA that they may leave the facility unassisted, due to Assisted Living (Independent Living) at Brookdale. However, immediate assistance can also be provided by the staff upon residents’ request. All residents interviewed expressed no concerns regarding this allegation and informed LPA that staff is very well trained to provide extra attention, care and supervision to all residents. Based on interviews and record reviews R1 did not wander from the facility as R1 was independent and able to leave this facility as desired. Therefore, this allegation is deemed Unsubstantiated, at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 31-AS-20250122143226

Allegation investigated: Staff is not feeding an adequate amount of food to residents in care. Facility is not following posted menu.

At 09:30am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi, conducted a subsequent visit to deliver final report. LPAs met with the Executive Director and explained the reason for the visit. During the initial visit, conducted on 09/18/24, LPA requested resident and staff roster. At 09:45am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Menu, relevant to the investigation. At approximately 09:50am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:00am - 02:30pm, LPA interviewed the Executive Director, Health and Wellness Director (LVN), MedTech, two (2) staff and twelve (12) out of thirteen (13) residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff is not feeding an adequate amount of food to residents in care. It was alleged that residents are only served a bagel with cream cheese and jelly for breakfast. To investigate this allegation, at approximately 10:00am, LPA made a visit to the kitchen and observed it is fully stocked with perishable and non-perishable foods. LPA also observed the residents with special dietary needs are posted in the kitchen prep area with pictures of the residents and their food choices or required preparation. Interview with the Chef and a cook revealed that the food is restocked regularly at least 2 times a week, on Monday and Thursday. The document review of food options revealed facility provides variety of food that include protein, grains or starch, vegetables, dairy, and fruits or juice daily. LPA observed the lunch ingredients being prepared for the day as followed: steak and potato soup, carnitas, grilled shrimp, mixed green salad and creamy mushroom pork chops. Additionally, LPA was informed that an alternative menu for breakfast, lunch and dinner is also available (daily). Review of the facility menu (for 09/18/24) confirmed the accuracy of providing meals for that day. Interviews with the Chef, cooks and the Administrator also revealed that the residents never had any concerns and that the staff will also customize food being served upon resident's request. Twelve (12) out of thirteen (13) residents interviewed expressed no concerns regarding this allegation and informed LPA that the facility always provides adequate food for breakfast, lunch and dinner. Based on LPA's interviews, observation, and document review the above allegation is found Unsubstantiated, at this time. Allegation: Facility is not following posted menu. To investigate this allegation, LPA conducted a tour in the kitchen, and interviewed staff and residents. Interviews with twelve (12) out of thirteen (13) residents revealed that the facility always follows the daily menu. All residents interviewed expressed no concerns regarding this allegation. Moreover, interview with the Chef and a cook revealed that very rarely, due to the shortage of ingredients and or staff (since some meal preparations can be time consuming), the facility may change the menu. However, once that happens, all residents are made aware of the changes, promptly. Lastly, at 11:30am, while interviewing residents in the dining area, LPA observed lunch being served is consistent with the daily menu. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated, at this time. No citations issued during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 31-AS-20240913143615

Type of visit: Case Management - Other

At 1:30pm, Licensing Program Analyst (LPA), Angela Panushkina, along with the Ombudsman, Eleanor Shenier, conducted a Case Management visit. The team met with the Administrator, and explained the reason for the visit. LPA requested resident and staff roster. During the visit conducted on 03/05/25, LPA was informed that the facility had approximately twenty (20) non-ambulatory residents residing on a second floor. During today's visit, the team was informed that the Eviction letter was already issued to all non-ambulatory residents (on a 2nd floor) on 03/11/24 and as of now, majority of residents have been already relocated downstairs. Currently there are eight (8) out of twenty (20) residents are still in a process of moving downstairs by 04/11/25. The team was also informed that a Written Plan, initially submitted on 12/19/24 was slightly changed to the following: "Facility increased the frequency of monitoring residents and updating Fire Watch log every two (2) hours" as of 04/01/2025. LPA obtained a copy of the new Written Plan and Fire Watch log during today's visit. No deficiency issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 3, 2025

Allegation investigated: Resident was sexually abused by another resident in care.

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Executive Director and explained the reason for the visit. On 03/12/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident was sexually abused by another resident in care." The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Jose Santana. On 03/14/24 LPAs Panushkina, Ngo-Castaneda, and Khurshudyan initiated the complaint. LPAs conducted tour of the facility and obtained copies of pertinent information which include but not limited to Physician’s Report dated on 09/28/23, Admission Agreement dated on 09/30/23, Progress Notes from 02/21/24 to 02/26/24, related to the complaint. Continue on LIC9099-C Substantiated No updated resident appraisal observed. LPAs conducted interviews with the Administrator and nine (9) out of fourteen (14) residents, who were able to communicate. On 03/21/24, LPAs Panushkina and Ngo-Castanega along with the Investigator, Jose Santana, from the Investigation Branch conducted a subsequent visit to interview R1. Investigator Santana, conducted interviews with, Resident #1/R1 (on 03/21/24, 3/29/24, 4/3/24 and 5/1/24), R2 (on 05/01/24), R3 (on 03/27/24), R1's Social Worker and Case Manager (on 03/19/24), Primary Care Physician (on 03/28/24). On 3/22/2024 IB subpoenaed R2 records from LASD Records and Identification Bureau. On 3/27/2024, IB also subpoenaed R1's medical records from 2/20/2024 – 3/27/2024. Allegation: Resident was sexually abused by another resident in care. The investigation findings revealed that in the morning of 02/20/24 R2 entered the room of R3 and asked to inappropriately touch R3. The facility became aware of the incident but failed to address the matter of R2 at that time. As a result, R2 then entered R1’s apartment on the afternoon of 02/21/24 and sexually assaulted R1. Although, during the interview with the Investigator, conducted on 03/29/2024, the Administrator denied knowing that R1’s allegation included actual touching, it was reported by a facility’s MedTech on 2/22/2024 and was documented on the SOC341 on 2/21/2024. The facility again failed to follow Brookdale’s Abuse Policy where it indicated the following: “Brookdale is committed to maintaining a safe environment for clients, visitors and associates. Allegations of abuse, neglect or exploitation should be treated seriously and be reported to the Administrator or the supervisor on duty for investigation and follow-up. Upon receipt of an allegation of abuse, neglect or exploitation, the Administrator or designee should conduct a confidential internal investigation of the incident within 24 hours. In the event of suspected rape or sexual abuse, the facility is to develop a plan as soon as possible to protect the suspected victim. The suspected victim should have a medical examination. Evidence or potential evidence should be preserved… The agency should contact an agency or individual trained in sexual abuse to interview the client and provide counseling…” Had the facility investigated the 2/20/2024 incident, there is a possibility that the 2/21/2024 incident could have been prevented. Furthermore, the facility did not notify R1 who his/her perpetrator was, although, R2 has since departed the facility. Instead, the facility did ask R1 to not discuss the incident with other residents. Therefore, based on interviews and information gathered during this investigation, this allegation is Substantiated. Continue on LIC9099-C A $500 immediate civil penalty is assessed today for a violation resulting in sexual abuse to R1. The Licensee/Executive Director were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed, and delivered.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 31-AS-20240312124123

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1-3) · Plan of correction due date: Mar 13, 2025

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly… (1) To be accorded dignity… (2) To be accorded safe, healthful and… (3) To be free from punishment, humiliation, intimidation, abuse… This requirement is not met as evidenced by: Based on interviews , record reviews and review of facility policy the licensee did not comply with the section cited above by not investigating 02/20/24 incident which could prevent R1 being sexually assaulted by R2 on 02/21/24. This posed an immediate health and safety risk or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Administrator is no longer working at this facility. Current Administrator agreed to provide a vendorized training to all staff regarding this section. Administrator will submit the name, license number and a scheduled training date. Copy of certificates will be submitted upon completion. An immediate civil penalty in the amount of $500 is issued.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1-2) · Plan of correction due date: Mar 13, 2025

Administrator-Qualifications and Duties: The Administrator shall have the knowledge of the requirements for providing care and supervision... The administrator shall also have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews the Administrator did non comply with the section sited above by not following the facility’s Abuse Policy to hire a neurologist for R1 after the incident. This posed an immediate health and safety risk or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Administrator is no longer working at this facility. Current Administrator agreed to provide a vendorized training to all staff regarding this section. Administrator will submit the name, license number and a scheduled training date. Copy of certificates will be submitted upon completion

Type of visit: Case Management - Other

At 1:00pm, Licensing Program Analyst (LPA), Angela Panushkina, Fire Inspector, Linsay Pellegrini along with the Building Mechanical Inspector, Ara Sinanian conducted a Case Management visit. The team met with the Health and Wellness Director, Anchirriza Concepcion, and explained the reason for the visit. LPA requested resident and staff roster. The facility currently has approximately twenty (20) non-ambulatory residents residing on a second floor. During the 10/10/24 and 12/17/24 visits, LPA informed the facility that this is a Health and Safety issue and requested to provide a Written Plan within 48-hours. However, during today's visit, a third request was made for the facility to submit a written plan. The team was informed that the facility continues to conduct routine checks on non-ambulatory residents every two (2) to four (4) hours. At 1:50pm, Executive Director contacted the LPA and the team conducted an interview over the phone. The Building Mechanical Inspector confirmed during the interview that the facility is operation outside their certificate of occupancy. The team was informed that the facility currently has twenty (20) non-ambulatory residents still residing on a second floor and Brookdale’s District is currently working on an issuance of a letter that will be send to residents/families regarding the relocation. The team was informed that by the end of March 2025 all non-ambulatory residents from the second floor will be relocated/moved. No deficiency issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: Staff does not ensure resident's bathing needs are being met. Staff leaves resident soiled for extended periods of time.

At 09:50am, Licensing Program Analyst (LPA), Angela Panushkina, arrived at Brookdale Chatsworth in response to the above-mentioned allegations. LPA met with the Health and Wellness Director and Business Office Manager and explained the reason for the visit. At 09:55am, LPA requested resident and staff roster. At 10:00am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Staff Training, Shower Log, relevant to the investigation. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:20am - 02:30pm, LPA interviewed the Business Office Manager (BOM), Health and Wellness Director (HWD), four (4) staff and eleven (11) out of twelve (12) residents. Also, while interviewing a sample of twelve (12) residents, LPA randomly tested three (3) resident pendants. Continue on LIC9099-C Unsubstantiated Allegation: Staff does not ensure resident's bathing needs are being met. It was alleged that the facility do not care for R1's hygiene/shower in a timely manner. To investigate this allegation while interviewing a sample of twelve (12) residents, LPA conducted a random inspection of three (3) pendants and staff responded within a reasonable time. Interview with the Business Office Manager (BOM) and Health and Wellness Director (HWD) revealed that the facility’s expectation for response time is 15 minutes. In addition, BOM and HWD informed LPA that all residents are provided showers at least twice a week or as needed. LPA conducted interviews with four (4) staff members, and all parties interviewed confirmed the statements provided by BOM and HWD. Interviews with four (4) staff also revealed that they respond to residents' call buttons immediately and if the staff member is not available to assist, they communicate with each other to make sure the call/page is taking care of right away by the next available staff. Interviews with eleven (11) out of twelve (12) residents expressed no concerns regarding the above allegation. Based on interviews and the information received, allegation is deemed Unsubstantiated at this time. Allegation: Staff leaves resident soiled for extended periods of time. It was alleged that R1 was left in his/her own feces and not being cleaned. To investigate this allegation LPA conducted an interview with the Business Office Manager (BOM), Health and Wellness Director (HWD) and was informed that all incontinent residents are scheduled to be changed every two hours or as needed. Furthermore, interview with four (4) staff members confirmed the statement provided by the BOM and HWD. LPA was also informed that R1 was able to independently care for self. LPA conducted an interview with R1 and was informed that he/she is independent and requires no assistance from the staff. Lastly, eleven (11) out of twelve (12) residents interviewed, expressed no concerns regarding this allegation. Based on the information obtained through interviews, there was insufficient evidence to prove R1 was left in soiled for an extended period of time. Therefore, the allegation is deemed Unsubstantiated at this time. No deficiency issued during todays visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 31-AS-20250210124020

Type of visit: Case Management - Other

At 9:00 am, Licensing Program Analysts (LPAs), Nadia Shahbazian and Angela Panushkina conducted a Case Management visit. LPAs met with the Executive Director, Amanda Monroy, and explained the reason for the visit. At 9:10am, LPAs requested resident and staff roster. At approximately 9:25am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. During the 12/17/24 visit, LPA Panushkina was informed that the facility had approximately thirty seven (37) non-ambulatory residents residing on a second floor. During todays visit, LPAs informed that the facility currently has twenty seven (27) non-ambulatory residents residing on the second floor. Also, LPAs were informed that on December 2024 facility hired an Architect who is currently working on a plan to be approved by the Building and Safety Department. LPAs obtained the copy of documents. Additionally, LPAs were informed that the facility is working with the Fire Inspector to make appropriate changes to expedite the new plans for the second floor non-ambulatory approval. Lastly, Administrator informed LPAs that the facility staff continues to conduct routine checks on non-ambulatory residents, on a 2nd floor, every two (2) hours. No deficiency issued during todays visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Case Management - Other

At 10:30am, Licensing Program Analyst (LPA), Angela Panushkina, Regional Manager (RM), Angela Wittaker, Licensing Program Manager (LPM), Nichelle Gillyard along with the Fire Inspector, Linsay Pellegrini conducted a Case Management visit. The team met with the Executive Director, Amanda Monroy, and explained the reason for the visit. LPA requested resident and staff roster. The facility currently has approximately thirty seven (37) non-ambulatory residents residing on a second floor. During the 10/10/24 visit, LPA informed the facility that this is a Health and Safety issue and requested to provide a Written Plan within 48-hours. However, during today's visit, a second request was made for the facility to submit a written plan. The team was informed that the facility continues to conduct routine checks on non-ambulatory residents every two (2) to four (4) hours. Executive Director will submit the Written Plan to LPA within 24-hours. In addition, Executive Director was provided a copy of the occupancy certificate, issued by Building and Safety, which indicates "No Non-Ambulatory" residents on a second floor. At approximately 11:00am, LPA, LPM, RM and the Fire Inspector conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Fire Inspector recommended a search protector to be used for all decoration cords. A chair in a hallway, by the room #120, blocked the clearance and the Fire Inspector requested the chair to be removed/relocated. At 11:30am, the team went up the stairwell to inspect the roof access. Executive Director informed the team that once the door opened, each employee receives a notification on their pagers for an immediate assistance. The Fire Inspector recommended an auditory alarm also to be placed on all "roof access" doors for an extra safety. It was observed that Maintenance storage door and housekeeping carts which stored chemicals were unlocked and upon request the Executive Director immediately locked and removed all chemicals. The team requested an additional training/meeting to be provided to all staff. No deficiency issued during todays visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent Annual Visit to complete the report. LPA met with the Executive Director, Amanda Monroy, and explained the reason for the visit. During the physical plant tour, conducted on 11/26/24, LPAs observed the following: Upon entry into the room #207, LPAs observed the Resident #10 (R10) in a hospital bed which was placed against the wall and the bed was blocking the passageway. Bathrooms: At 11:53am LPAs observed six (6) loose pills placed on a top of the vitamin bottle in room #159. During the interview with the resident, LPAs were informed that the pills were placed on a bottle as a reminder to take them later. LPA requested all six (6) pills to be properly discarded. LPAs also observed filthy/dirty bathrooms in room #207, #159, #175 and #401. Appropriate grab bar and non-skid mat were also observed. The hot water temperature measured between 108.6-133.4°F. Lastly, LPAs observed walls in various rooms, bathrooms and hallways to be poorly scraped and the paint around the door jamb is peeling away, door knobs are loose/damaged and trash cans were missing the fitted lids. Outside areas: While walking towards the West Wing area, LPAs observed that an exit, double doors were open and a ceramic, chipped roof tiles were placed under the door to prevent them from closing. LPAs also observed seventeen (17) extra ceramic roof tiles placed on the grass, of which one (1) tile was broken. Moreover, the metal gutter on a second floor, by the room #287 was twisted/loose/falling apart. In addition, at 12:08pm, LPAs observed piece of molded carpet outside, under the balcony (room #182). Continue on LIC809-C At 12:21pm, on a 2nd floor of the West Wing side, LPAs observed a missing doorknob/lock. LPAs were informed that the room is used as a storage for a maintenance crew. LPAs opened the door and observed a molded wall, ceiling and fifteen (15), five (5) gallon paints on the floor accessible to residents in care. Furthermore, at 12:29pm, upon entry into the room #401, LPAs observed an “Oxygen in Use” sign missing (resident uses an oxygen tank/concentrator). In addition, LPAs observed two (2) area rugs in room #401 are wrinkled which can cause a tripping hazard. Lastly, various areas (by rooms #301, #418, #420 and #421) in hallways, were observed to have a leak on a ceiling and two (2) fire doors (by rooms #241 and #408) were broken/damaged. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. Kitchen: At 1:05pm, LPAs toured the kitchen and observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. All knives and sharps in the kitchen were kept locked and inaccessible to residents in care. There are three (3), fully charged fire extinguishers by the kitchen. All trash cans had fitted lids to protect from cross contamination. Laundry: There are four (4) laundry rooms throughout the facility. LPAs observed all detergents locked and inaccessible to residents in care. Resident Files: Between 1:30pm to 4:30pm, LPAs conducted eighteen (18) resident and five (5) staff records review. The following was observed. Fifteen (15) out of eighteen (18) resident files were incomplete. Files were missing signed list of personal property (LIC621) for R3 and R9, Physician’s Report (LIC602) missing R6’s, R8’s and R10’s signatures/dates, ID/Emergency Information (LIC601) missing the date next to R9’s signature, Resident Preplacement (LIC603) missing signatures/dates and or 2nd page for R1, R2 and R8 and Release of Medical Information (LIC605A) are missing or have not been signed for R5, R7 and R10. Please see LIC858 included with this report. Staff Files: The following was observed. LPAs observed five (5) out of five (5) employee files were missing personnel records (LIC501). Documented medications and general training observed to be completed. Please see LIC859 included with this report. Deficiencies and civil penalty issued on LIC809-Ds. Exit interview conducted, appeal rights explained and copy of report signed and deliveredthe state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi, conducted unannounced annual visit. LPAs met with the Operations Specialist/Administrator - Dimple Kamdar and Business Office Manager - Veronica Gomez and explained the reason for the visit. Upon arrival, LPAs requested facility Staff and Resident Roster. LPAs were informed that the facility currently has one hundred and twenty eight (128) residents and four (4) caregivers and two (2) MedTechs. At 9:30am, LPAs conducted a physical plant tour with the Business Director and the following was observed: Common Areas: The facility maintains a comfortable temperature at 72°F. There are approximately one hundred and eighty (180) rooms at the facility. Moreover, LPAs were informed that the facility has three (3) libraries, two (2) activity rooms, a movie theater and a dining area. Facility has four (4) medication carts throughout the facility (Cart #1 by room #302, cart #2 by room #179, cart #3 by room #140 and cart #4 by room #224) and LPAs observed all carts locked and inaccessible to residents. Fire extinguishers were last serviced on 03/27/2024. Smoke detectors are tested annually by the Fire Department and LPAs obtained a copy of the report dated on 08/24/2024. Bedrooms: LPAs observed three (3) half rail beds in rooms #421, #202 and #214 and one (1) full bed rail bed in room #228. Physician's order for half/full bed rails were not available upon request. In addition, at 12:49pm, LPAs passed by room #404 and observed a strong urine like smell. LPAs were informed that the facility does carpet deep cleaning every other day, however, the facility still can't get rid of the smell. Moreover, LPAs observed dirty carpets in the following rooms: #204, #256, #244 and #175 and in hallways. LPAs requested all room and hallway carpets to be cleaned. Furthermore, LPAs observed room #230 and #228 had an audio and video surveillance. LPAs requested all audio to be turned off immediately. Continue on LIC809-C Due to time constraints, LPAs were unable to complete the annual visit. LPAs will conduct a follow up visit to finish the report/deficiencies on another day. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 26, 2024

Allegation investigated: Staff does not respond to resident’s pendant call. Staff not maintaining resident’s hygiene.

At 09:00am, Licensing Program Analysts (LPAs), Angela Panushkina and conducted a subsequent visit to deliver final report. LPAs met with the Operations Specialist - Dimple Kamdar and Business Office Manager - Veronica Gomez and and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit. Initial visit was conducted on 10/09/24 and during course of the investigation, LPA requested resident and staff roster. At 09:45am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Shower Log, Alarm History (pendant and emergency pull cords) for the months of September 2024 and Staff Training relevant to the investigation. At approximately 10:00am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 02:00pm, LPA conducted an interview with the Business Office Manager, four (4) staff, and eight (8) out of thirteen (13) residents. Continue on LIC9099-C Substantiated LPA randomly tested resident’s pendant and emergency pull cords in rooms and bathrooms. Allegation: Staff does not respond to resident’s pendant call. It was alleged that the facility staff do not respond to residents' pendant and emergency pull cords. To investigate this allegation, during the initial visit, LPA conducted a random inspection of three (3) pendants and five (5) emergency pull cords in resident's rooms and bathrooms. The facility’s expectation for response time is 10-15 minutes. During the inspection two (2) pendant calls were addressed within the facility time frame. However, the third pendant call was made at 11:07am and was not reset by the facility staff until LPA asked S2 to reset it at 11:33am (26 minutes later). Moreover, at 11:58am LPA tested bathroom emergency cord in room #319 and S3 came into the room at 12:06pm and reset the room pull cord instead. In addition, at 12:23pm LPA tested room and bathroom emergency cords in room #148 and S1 came into the room and reset the bathroom cord only. Furthermore, at 12:23pm LPA tested the room emergency cord in room #315 and waited until 12:38pm. No staff showed up to reset the emergency cord. Lastly, review of facility Alam History from 09/10/24 (12:56pm) to 09/30/24 (6:44pm) revealed that six hundred forty-five (645) pendant/pull cord calls were resolved between sixteen (16) minutes to one (1) hour and twenty-seven (27) minutes later. Based on LPA's observation, inspection and record review this allegation is Substantiated. Allegation: Staff not maintaining resident’s hygiene. It was alleged that on 09/09/24 R1 was transferred from the hospital to sub-acute rehabilitation for 2 weeks and when R1 came back to the facility from the hospital/rehabilitation on 09/24/24, no shower was provided to R1 until 10/05/24. To investigate this allegation, LPA conducted interviews with the Wellness Director and Business Office Manager. Interview with both parties revealed that R1 refused to have a shower. Facility has a document signed by the resident when they refuse showers. However, the facility could not provide LPA the proof that R1 did refuse shower for that week. Moreover, LPA conducted review of the facility shower log and observed that R1 was scheduled to have a shower on 10/05/24, but no shower was scheduled prior to that day. Therefore, based on interviews and record reviews this allegation is Substantiated. Deficiencies issued per Title 22 on LIC9099-D Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 31-AS-20241002095036

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(2) · Plan of correction due date: Nov 24, 2024

Maintenance and Operation: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful... ...furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs inspection the licensee did not comply with the section cited above. Staff did not respond to 2 out of 3 resident’s pendant and 3 out of 3 emergency cord devices, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee/Administrator will test all residents’ pendants and emergency cords and provide an in-service training to all staff. Copy of training will be submitted to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Nov 28, 2024

Basic Services: (d) if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... and providing the other basic services. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not arranging/scheduling a shower for R1 for over two (2) weeks, which poses/ posed a potential Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee will provide an in-service training and submit proof of training to LPA

Allegation investigated: Staff did not seek medical attention to resident in a timely manner. Staff left resident soiled for an extended period of time.

This is an Amendment to the original report issued 11/22/2024. Additional information was added to clarify the investigation. At 09:00am, Licensing Program Analysts (LPAs), Angela Panushkina and Nadia Shahbazian conducted a subsequent visit to deliver final report. LPAs met with the Operations Specialist - Dimple Kamdar and Business Office Manager - Veronica Gomez and and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit. During the initial visit, conducted on 07/03/24, LPA requested resident and staff roster. At 10:15am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Staff Training, relevant to the investigation. At approximately 10:25am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am - 1:40pm, LPA interviewed the Administrator, one (1) MedTech, three (3) staff and eleven (11) out of thirteen (13) residents. and bathrooms. LPA also conducted a phone interview three (3) out of three (3) night shift staff members. Lastly, LPA requested/reviewed R1's Medical Records. Unsubstantiated Allegation: Staff did not seek medical attention to resident in a timely manner. Staff left resident soiled for an extended period of time. The investigation findings revealed that R1 had been living at this facility since February 28th, 2024, and due to severe emphysema, R1 used full-time oxygen. Review of R1’s facility records revealed that R1 was able to independently get in and out of the bed (based of the Physician’s Report - dated on 02/01/24). Moreover, based on facility’s “Preplacement Appraisal Information”, dated on 02/10/24, R1 was able to independently ambulate throughout the facility and only required assistance with bathing. Interview with the Business Director and three (3) staff, revealed that all incontinent residents are scheduled to be changed every two (2) hours or as needed. Moreover, LPA was informed that the night shift is conducting round checks at least every 2 hours. However, some residents do not want to be disturbed and to be checked on at nights. R1’s first fall incident occurred on 06/24/24 at 9:15am and the facility called 9-1-1. When the paramedics arrived, R1 was able to answer all questions and R1 refused paramedics help when asked. However, due to this incident, the facility staff was instructed to frequently check on R1 and obtain his/her vitals, (i.e. R1’s blood pressure, check for signs of injury, and monitor for any changes in the resident.) During the interview with S3, LPA was informed that on 06/25/24, S3 started their shift at 10:00pm and at around 10:10pm, while conducting their first-round check, S3 visited R1’s room and observed that R1 was already in bed. After finding out that R1 does not require any assistance, S3 wished R1 good night sleep and left the room. At around 1:30am, S3 came back to check on R1 and found R1 unresponsive on the floor. Based on the facility's “Fall Policy”, the staff can't move/relocate/touch an unconscious resident. Interview with S3 revealed that upon discovery of R1’s incident, S3 immediately contacted the MedTech (the staff are trained to immediately notify the MedTech, who then will contact 9-1-1 and wait for the Paramedics to arrive). All parties interviewed denied the above allegations and informed LPA that the staff did follow the facility's Policy and timely medical attention was provided to R1. Moreover, eleven (11) out of thirteen (13) residents interviewed expressed no concern regarding the above allegations. LPA was informed that the facility staff are well trained to provide immediate medical attention in emergency situations and all incontinent residents are always provided proper assistance timely. Although LPA was unable to interview R1, LPA conducted an interview with R1's family member, who also expressed no concerns regarding the above allegations. Based on the information obtained through interviews, there was insufficient evidence to prove that staff did not seek medical attention to resident in a timely manner and R1 was left in soil for an extended period of time. Therefore, based on interviews, and information gathered, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and deliveredthe state’s words, verbatim · CDSS document, Nov 22, 2024 · control 31-AS-20240628153636

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control # 31-AS-20240628153636. LPA met with the Operations Specialist - Dimple Kamdar, Business Office Manager - Veronica Gomez and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit. On 06/28/24, the Regional Office (RO) received a complaint and on 07/03/24, LPA conducted an initial complaint visit. During the complaint investigation, LPA discovered that prior to R1’s fall incident that occurred on 06/25/24 (at around 2:30am), R1’s AC/Heater Unit was not properly working, and the initial work order was submitted on 06/23/24. Interview with the witness revealed that during the visit conducted on 06/25/24 they observed that R1’s AC/Heater Unit was still not fixed, and another work order was immediately submitted. Additionally, LPA conducted interview with three (3) staff members, who also confirmed that on a day of the incident they observed R1’s room temperature to be very high/hot and discovered that the AC/Heater Unit was broken. Lastly, LPA requested facility’s work order for R1’s AC Unit and observed that on 06/25/24 at 1:13pm an order was placed by R1’s family member. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC809-D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Nov 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 28, 2024

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA’s interviews, inspection and record review, the licensee did not comply with the section cited above by not addressing R1’s AC/Heater Unit issue properly (on 06/23/24). A witness had to place another work order on 06/25/24, after R1’s 2nd fall incident, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Administrator will submit proof upon complition of the AC unit to LPA by POC date.

Type of visit: Case Management - Other

At 9:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Nadia Shahbazian conducted a subsequent, Case Management Visit to follow up on eighteen (18) non-ambulatory residents’ status. LPAs met with the Operations Specialist - Dimple Kamdar and Business Office Manager - Veronica Gomez and and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit. The facility was already warned by the Regional Office and the Fire Department that the Certificate of Occupancy stated that this building could not have non-ambulatory residents on the 2nd floor and the Fire Clearance issued, during the initial licensure that had been in place for over 20 years, was approved in error and must be corrected. During the initial, Case Management Visit conducted on 10/10/2024, LPA Panushkina was informed that eighteen (18) non-ambulatory residents were residing on a second floor. The facility also provided names and apartment numbers for all eighteen (18) residents. The Regional Office requested all eighteen (18) residents to be moved/relocated to the 1st floor. During today’s visit LPAs toured all eighteen (18) non-ambulatory residents’ apartments on the 2nd floor , with the Health and Wellness Director (HWD) and discovered that one (1) more resident from Unit #404 was also non-ambulatory and received hospice. Moreover, during the visit, LPAs were informed that one (1) out of nineteen (19) residents had passed away on October 28th, 2024. Additionally, three (3) out of eighteen (18) non-ambulatory residents interviewed, informed LPAs that they are in a process of moving to a different facility (estimated time: by December 15th, 2024). Facility continues to conduct routine checks on non-ambulatory residents every two (2) to four (4) hours. However, facility did not and could not provide a log. LPAs requested the HWD to create and keep a log for frequent checks for non-ambulatory residents. No bedridden residents were currently residing on a second floor. Although, LPAs were informed that the facility follows the regulations, LPAs did not observe any additional safety measures from the last visit (conducted on 10/10/24). Continue on LIC809-C Lastly, during the physical tour, LPAs observed the facility had six (6) evacuation chairs in stairwell. LPAs were informed that the last fire disaster drill was conducted on 10/14/2024 and the last evacuation drill was conducted on 09/12/2024. LPAs obtained copies of the drills from June 2024 to October 2024. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: Case Management - Other

A case management visit was conducted by Licensing Program Analyst (LPA) Angela Panushkina today based on a facility’s Non-Ambulatory status (for the 2nd floor) approved in error by the Fire Department in 1995 and 2011. LPA met with the Operations Specialist - Dimple Kamdar, District Director of Clinical Services - Leslie Tripp, Business Office Manager - Veronica Gomez, Wellness Director (LVN) - Anchirriza Concepcion and explained the reason for the visit. The facility is currently cleared for 258 Non-Ambulatory residents on a 1st and 2nd floors with capacity of 268. Cleared for 10 Bedridden in rooms #107, 111, 119, 121,123,127, 161, 163, 165, 167. It was determined that there as a "Clerical error" made, twenty (20) years ago. Due to the Fire Clearance Safety Regional Office (RO) is requesting for an additional monitoring on 2nd floor. LPA informed the facility team, as this is a Health and Safety issue, to provide a following Written Plan within 48-hours: 1. A list of people that need to be relocated (non-ambulatory and or bedridden on a 2nd floor). LPA was informed that no bedridden residents currently reside on the 2nd floor. As for Non-ambulatory residents, the facility will submit Names and Room #'s of each resident by 5:00pm on 10/10/24. 2. Anticipated move for those residents will be as follows: LPA was informed that the families/residents must be informed and upon approval the family/resident will coordinate and organize the transfer with the help of community. An addendum must be in place and attached to a current Admission Agreement, due to room changes and pricing. Continue on LIC809-C 3. When the facility anticipates completing this request by? LPA was informed that the Corporate Office will be contacted and more detailed information will be provided promptly. LPA also informed the Operations Specialist, District Director of Clinical Services, Business Office Manager, and Wellness Director (LVN) that more frequent supervision on a 2nd floor, during this time, is required. All parties have agreed to include additional supervision on a 2nd floor, and in a mean time will have a consultation with their Legal Team. No deficiencies issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 10, 2024

Allegation investigated: Staff does not respond to resident’s pendant call. Staff not maintaining resident’s hygiene.

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Executive Director and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Shower Log, etc., relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPAs interviewed the Executive Director, two (2) MedTechs, two (2) staff, Maintenance Tech and seven (7) residents. Also, while interviewing a sample of seven (7) residents, LPAs randomly tested resident’s pendant and emergency call buttons in bathrooms. Continue on LIC9099-C Substantiated Allegation: Staff does not respond to resident’s pendant call. It was alleged that the facility staff do not respond to residents' pendant and emergency pull cords. To investigate this allegation, LPAs conducted a random inspection of two (2) pendants and three (3) emergency pull cords in the bathrooms. The facility’s expectation for response time is 10-15 minutes. However, during the inspection only one (1) pendant call was received by the facility and a caregiver responded to the call in seventeen (17) minutes. Moreover, at 2:36pm, LPAs along with the Executive Director tested residents' pendant and emergency cord in room #153 and waited until 2:56pm. No staff showed up to reset the call buttons. Based on LPA's observation and review of the information received, this allegation is Substantiated. Allegation: Staff not maintaining resident’s hygiene. It was alleged that on 03/31/24 R1 came back from the hospital/rehabilitation and was not given a shower since the facility had no shower chair. To investigate this allegation, LPAs conducted interviews with the Executive Director, two (2) MedTechs and one (1) out of two (2) staff members. Interview with the Executive Director and facility staff revealed that R1's family was requested to purchase/provide a shower chair, which was delivered on 04/15/24. Although the shower chair was already delivered/received, it was not assembled until 04/16/24. Moreover, LPAs conducted review of the facility shower log and observed that R1 was scheduled to have a shower on 04/15/24, but no shower was provided to the present day. Therefore, based on interviews and record reviews this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director. It was alleged that the resident sustained unexplained fracture while in care. To investigate this allegation, LPAs conducted an interview with R1 and were informed that he/she lived at this facility since 2017 and required no help of any kind. LPAs were also informed that on 03/20/24, while walking towards the lobby, to pick up the mail, R1 did not buckle the footwear properly which led R1 to twist the ankle and lose balance. 9-1-1 was called and R1 was taken to the hospital and diagnosed with Right Femur and Right Humerus Fracture. Although the resident sustained unexplained fracture, interview with R1 revealed that he/she is happy with the care provided and did not blame the facility for the incident. Based on interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 17, 2024 · control 31-AS-20240416105120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(2) · Plan of correction due date: Apr 24, 2024

Maintenance and Operation: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs inspection the licensee did not comply with the section cited above. Staff did not respond to 2 out of 3 resident’s pendant and 3 out of 3 emergency cord devices, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee/Administrator will test all residents pendants and emergency cords and provide an in-service training to all staff. Copy of training will be submitted to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Apr 24, 2024

Basic Services: (d) if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... and providing the other basic services. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not arranging/scheduling a shower for R1 for over two (2) weeks, which poses/ posed a potential Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee will provide an in-service training and submit proof of training to LPA

Type of visit: Case Management - Deficiencies

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, Perchui Milena Khurshudyan and Leslie Ngo-Castaneda, conducted a Case Management Visit in conjunction with the complaint #31-AS-20240312124123. LPAs met with the Administrator explained the reason for the visit. At 10:49am, LPAs conducted visits to random resident rooms and conducted an interview with eight (8) out of fourteen (14) residents. Upon entry to three (3) out of six (6) rooms LPAs noticed the following: Dirty carpet in room #155 & #161 Two (2) loose window screens and broken window locks in room #159 LPAs also observed a cracked window, in a hallway, across from room #154 Deficiencies cited on LIC9099-D, based on LPAs observation of the physical plant. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 13, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 20, 2024

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPAs observation licensee did not comply with the section cited above, by not ensuring that three (3) out of six (6) resident rooms are in good repair, including the cracked window in a hallway. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: Administrator agreed to submit proof of picture or an invoice with by POC date.

Allegation investigated: Facility staff did not respond to resident's call button in a timely manner resulting in a fall Facility staff do not properly assist resident with toileting needs

At 09:00am, Licensing Program Analyst (LPA) Angela Panushkina, conducted an unannounced subsequent visit to deliver final findings. LPA met with the Business Office Manager and explained the reason for the visit. During the initial visit made on 11/16/2023, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Appraisal Needs and Services, Emergency Call Log, etc., relevant to the investigation. At approximately 10:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am – 1:30pm, LPA interviewed the Administrator, Health and Wellness Coordinator, four (4) staff, and ten (10) out of twelve (12) residents. Also, while interviewing a sample of 12 residents, LPA randomly tested resident’s pendant and emergency call buttons in bathrooms. Continue on LIC9099-C Unsubstantiated Allegation: Facility staff did not respond to resident's call button in a timely manner resulting in a fall To investigate this allegation while interviewing a sample of twelve (12) residents, LPA randomly tested resident’s pendant and emergency call buttons in their rooms. LPA conducted a random inspection of four (4) pendants and two (2) emergency call buttons, at Assisted Living (AL) Unit, and staff responded within a reasonable time. Interview with the Administrator and Health and Wellness Director revealed that the facility’s expectation for response time is 15 minutes. Moreover, interviews with four (4) staff members revealed that they respond to residents' call buttons immediately and if, for any reason, a staff member is not available to assist, they communicate with each other to make sure the call/page is being taking care of right away. In addition, interviews with ten (10) out of twelve (12) residents revealed that the staff always response within 5-10 minutes. Moreover, during the interview with R1, R1 expressed no concerns about the above allegation and informed LPA that the facility staff checks on him/her frequently. However, R1 forgets to press the pendant for an assistance before getting up from the bed and due to his/her medical condition R1's legs give out resulting R1 to fall. Based on interviews and review of the information received, allegation is deemed Unsubstantiated at this time. Allegation: Facility staff do not properly assist resident with toileting needs Interviews with the Administrator and four (4) staff revealed that all residents are being changed at least three (3) times per shift and or as needed. Moreover, LPA was informed that all residents are verbal, and when they ask for toileting needs, an immediate assistance is provided by the staff. LPA was able to interview ten (10) out of twelve (12) residents regarding this allegation. Ten (10) residents interviewed confirmed that they are assisted to the restroom, whenever they request to be taken and that has not been a concern. Based on interviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed an delivered.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 31-AS-20231106160805

Allegation investigated: Staff do not ensure that hot water is available to residents in care.

On 01/18/24 at 10:00 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with Executive Director (ED) Danny Vera and explained the reason for the visit. At 10:50 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were made. LPA requested resident roster and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to, maintenance logs, copy of receipts and correspondence to residents. Continued on 9099-C Unsubstantiated Allegation#1: Staff do not ensure that hot water is available to residents in care. LPA interviewed the ED and conducted a physical inspection of random resident rooms. Hot water ranged from temperatures of 117.6, 107.8, 105, 117.8 and 105, which is in compliance with Licensing regulations. Although the ED confirmed the hot water was out, a repair company came the same day that the facility was made aware of the problem and attempted to find the cause. The repair person came out for four (4) days in a row to determine the cause of the problem. It was determined that the piping in one of the rooms was backwards and was throwing off the rooms that were affected. Once the problem was found, the repairs began, and the hot water was reinstated on the fourth day 01/09/2024. In the interim residents were offered other arrangements for accessing hot water. One of the vacant rooms (room 250) had a designated staff member to assist and coordinate showers from 8:00 am to 4:00 pm everyday until the issue was resolved. If the hours needed to be extended the facility was ready to accommodate. The ED sent out a flyer to all residents notifying them that the hot water was not operable but would be fixed as soon as possible. Interviews with eleven out of eleven residents confirmed that the facility notified them regarding the water issue and that it was in the process of being fixed. Interviews with five out of five staff members confirmed that residents were made aware of the situation and were offered an alternative to showering and accessing hot water. Therefore, based on physical plant inspection, and documentation received, the allegation is Unsubstantiated at this time. Exit interview conducted and a copy of this report was given to ED.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 31-AS-20240109130557

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced Case Management visit at this facility to follow up on the incident that occurred on 05/17/23. LPA met with the Health & Wellness Directior (HWD) and explained the reason for the visit. LPA conducted physical plant tour at around 10:30am, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. During the initial Case Management Visit, conducted on 05/24/23, LPA requested copy of facility documents relevant to the investigation and interviewed staff between 10:45am to 12:10pm. Interview, conducted with the Executive Director (ED), on 05/24/23, revealed that R1’s family reported an incident wherein R1’s prescribed pain medications (3 pills) were stolen by Staff #1 (S1) on 05/17/23 at 7:26am from R1’s room. LPA was also able to review a copy of a video footage related to the incident. Moreover, LPA was informed that on 05/18/23 at 8:00am S1 was suspended by ED, pending investigation. During the investigation conducted by ED, on 05/18/23 at 12:00pm, S1 confirmed that he/she took R1’s pain medications from R1’s room without a permission. ED informed LPA that right after the interview with S1, at 12:40pm, a police report was filed. On 10/09/23, LPA reviewed documents (all required training transcripts for S1 from 2021 to 2023, S1's fingerprint clearance and association to this facility, etc.) obtained during the initial visit, including SOC341, Incident Report and a Police Report. Based on interviews, record review and LPA's inspection it was found that ED reported the incident appropriately and S1's employment was terminated, immediately. During today's visit HWD and ED informed LPA that all staff completed in-service training regarding Theft and Loss Prevention, Elder Abuse, etc. LPA was also informed that all residents medication is kept locked. No deficiency will be cited at this time. Exit interview conducted and copy of this report signed and deliveredthe state’s words, verbatim · CDSS document, Oct 10, 2023